Sutton Beneficiary Designation

In this application, we, us and our refer to Sutton Special Risk. You and your refer to the person to be insured.

By completing this form, you are asking us to change the information you previously provided. Any previous beneficiary designation or trustee appointment is revoked. This designation will apply to the entire amount of your Doctors of BC Life Loss of Life benefit under the Accidental Death and Dismemberment insurance coverage and supersedes any previous beneficiary designation. (unless the previous beneficiary designation was irrevocable and written consent has not been received from the irrevocable beneficiary).

Policy Number

Certificate #

Doctors of BC #*

Name of Doctors of BC Member*

First NameMiddle NameLast Name

Member Birth Date*

DayMonthYear

Email

Confirmation Emailfor DocuSign purposes

It is important that you designate a beneficiary for the Loss of Life benefit under the Accidental Death and Dismemberment insurance. Your designated beneficiary is the person who you choose to receive the life benefit amount if you die accidentally. Failure to designate a beneficiary will result in any life claim being paid to your Estate. (Payment for all losses under the "dismemberment" portion of this policy, such as loss of limb, etc. are payable to you.)

A revocable beneficiary is someone you choose that can be changed at any time without their permission. An irrevocable beneficiary cannot be changed without the written permission of the irrevocable beneficiary.

If you designate more than one beneficiary, you must indicate the percentage of the claim to be paid to each beneficiary (the total percentage for all beneficiaries combined cannot be more than 100%).

You may want to designate a "contingent beneficiary" - an alternate beneficiary who you want to have the death benefit paid to in the event the beneficiaries you designated as primary beneficiaries are not living at the time of your death.

If you designate a beneficiary who is a minor (under the age of 18), please name a trustee to receive payment on behalf of the minor.

Primary Beneficiary (share benefits must add up to 100%)*

You have chosen to designate an irrevocable beneficiary. Is this your intent?

When you name an irrevocable beneficiary, you cannot make any changes to the policy (i.e. cancel, reduce benefits or change beneficiary) without the written consent of the irrevocable beneficiary.

Contingent Beneficiary (share benefits must add up to 100%)

You have chosen to designate an irrevocable contingent beneficiary. Is this your intent?

When you name an irrevocable beneficiary, you cannot make any changes to the policy (i.e. cancel, reduce benefits or change beneficiary) without the written consent of the irrevocable beneficiary. (If you name a minor as an irrevocable beneficiary, be aware they don't have legal capacity to consent to a change until they are age of majority).

Complete this section if a beneficiary named on this form is a minor. If so, you
agree that if the beneficiary is a minor on the date that benefits become payable,
the benefits will be paid to the trustee to hold in trust for the minor until the minor
comes of age.

Trustee for Minor Children

Date Signed*

Date

Beneficiary Designation

General Information

Beneficiary Designation

Signature